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PDL Status Values
Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the
Non-Preferred Drugs in Select PDL Classes prior authorization criteria.
New drugs will be listed as N until reviewed by the P&T Committee and are subject to the
New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.
To request a Prior Authorization, please use this form.
| Generic Name | Brand Name | Form | PDL Status |
Current Drug Use Criteria | New Drug Evaluation |
|---|---|---|---|---|---|
| COVID-19 vac, tris(Pfizer)/PF | COMIRNATY | VIAL | |||
| COVID-19 vac,Ad26(Janssen)/PF | JANSSEN COVID-19 VACCINE (EUA) | VIAL | |||
| COVID-19 vac,AZD1222(Astra)/PF | ASTRAZENECA COVID19 VAC(UNAPP) | VIAL | |||
| COVID-19 vacc, mRNA(Pfizer)/PF | COMIRNATY | VIAL | |||
| cytomegalovirus immune globuln | CYTOGAM | VIAL | |||
| hepatitis B immun glob/maltose | HEPAGAM B | VIAL | |||
| hepatitis B immune globulin | H-BIG | SYRINGE | |||
| hepatitis B immune globulin | HYPERHEP B | SYRINGE | |||
| hepatitis B immune globulin | HYPERHEP B | VIAL | |||
| hepatitis B immune globulin | NABI-HB | VIAL | |||
| hepatitis B immune globulin | H-BIG | VIAL | |||
| histoplasmin | HISTOPLASMIN | VIAL | |||
| rabies immune globulin/PF | HYPERRAB | VIAL | |||
| rabies immune globulin/PF | KEDRAB | VIAL | |||
| Rho(D) immune globulin | HYPERRHO S-D | SYRINGE | |||
| Rho(D) immune globulin | RHOGAM ULTRA-FILTERED PLUS | SYRINGE | |||
| Rho(D) immune globulin | RHOPHYLAC | SYRINGE | |||
| Rho(D) immune globulin/maltose | WINRHO SDF | VIAL | |||
| tetanus immune globulin/PF | HYPERTET | SYRINGE | |||
| tuberculin,purif.prot.deriv. | APLISOL | VIAL | |||
| varicella-zoster Ig/maltose | VARIZIG | VIAL |